MedPod Today: ‘Medical Freedom’; More Private Equity Harms; USMLE Cheating Scandal

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insights into the week’s biggest healthcare stories. I’m your host, Rachael Robertson.

Today, we are talking with Jennifer Henderson about the growing “medical freedom” movement. After that, Kristina Fiore will tell us about another way that private equity harms patients. Then Jennifer will interview me about the latest updates on the USMLE cheating scandal from last year.

The “medical freedom” movement emphasizes individual decision making over public health authorities’ recommendations. The movement has gained traction in the U.S. since the COVID-19 pandemic, but experts told MedPage Today that it could continue to push public health statistics in a troubling direction. Jennifer Henderson is here to tell us about it.

So Jennifer, what about medical freedom has experts concerned?

Jennifer Henderson: They were, in part, reacting to a recent New York Times story about how vaccine skeptics and others in the medical freedom movement are having more influence on American politics. For instance, KFF Health News reported how childhood vaccination rates have declined in recent years, while exemption rates have gone up.

In 2024, the percentage of U.S. kindergarteners with an exemption from at least one required vaccine increased at 3.3% – the highest percentage ever noted, according to the CDC. There also were more than 32,000 cases of pertussis, which surpassed pre-pandemic levels, and there were 16 measles outbreaks totaling 284 cases, up from just four outbreaks with 59 cases the year prior, CDC said.

Experts are concerned these figures may only get worse.

Robertson: Let’s back up a second. Why is medical freedom on the rise in the first place?

Henderson: Timothy Caulfield, professor of health law and science policy at the University of Alberta in Canada, told MedPage Today that it’s in part due to growing distrust when it comes to healthcare and scientific institutions, and that’s driven largely by the spread of misinformation, including about vaccines.

He put it this way: “In the past, you didn’t hear anti-vax rhetoric be such an explicit part of political platforms. … You didn’t hear the advocacy of unproven supplements as being part of political platforms. And now they are, and that signals to people that these beliefs are ideological flags. … These are the kinds of things that you should embrace.”

Additionally, it’s not surprising that the COVID pandemic accelerated the movement, experts said. In the early days of the pandemic, when there were no other treatments, people looked for drugs that would keep them out of the hospital, and they settled on the anti-malarial hydroxychloroquine and the anti-parasitic ivermectin, Dr. Paul Offit, of Children’s Hospital of Philadelphia, said. But even after studies showed the drugs’ lack of effectiveness against COVID, “people still didn’t want to believe it, and it went to the highest level.”

When everything first shut down in 2020 for quarantine, and then when people were asked to mask and test, this was seen as “massive government overreach,” he said. The same was true of COVID vaccine mandates for activities like entering restaurants, sporting events, or places of worship, even though in 2021 people were 12 times more likely to be hospitalized if they didn’t receive a vaccine, he said.

Robertson: So with this growing movement, what will help to protect public health?

Henderson: Caulfield said that addressing public health threats related to the medical freedom movement will be challenging going forward. Even just the word “misinformation” has become politicized, he said.

Offit pointed to history. Before the measles vaccine became available in 1963, about 400 to 500 people died from it each year, and some 48,000 people were hospitalized. About 1,000 developed encephalitis, or swelling of the brain that can lead to permanent damage.

He said: “We don’t fear it anymore because we don’t remember.” He’s referring to vaccine-preventable illness. “And so what gets our attention again, I think, is that children will, once again, have to suffer and die. I really do think that’s what it will take. And then the question is, how many, and I don’t know.”

Robertson: That’s pretty bleak. Thank you for this reporting, Jennifer.

Henderson: Thank you, Rachael.

Robertson: A growing body of evidence shows that patient outcomes get worse after private equity takes over hospitals. Now, new research published in JAMA shows that patients’ experiences of their care also deteriorates after a PE takeover. Kristina Fiore is here to tell us more.

Kristina, what’s the takeaway here?

Kristina Fiore: Basically, Harvard researchers found that measures of patient satisfaction declined after private equity took over hospitals. Now what makes this a really good study is that they didn’t just compare before and after at the acquired hospitals. They conducted what’s called a difference-in-differences analysis that compared the same before-and-after period — that’s 3 years before and 3 years after — at hospitals that were taken over by private equity versus those that weren’t.

The researchers used data from HCAHPS, which is a very well-known national patient survey, and they found that the percentage of patients rating hospitals highly, as like a nine or a 10 out of 10, was unchanged at private equity acquired hospitals, but it rose at matched control hospitals.

They also found that the percentage of patients who would definitely recommend the hospital fell at those that were acquired by private equity, while it increased at control hospitals. And those differences grew each year after the acquisition, reaching five percentage points by the third year.

Robertson: Was any aspect of patient satisfaction not affected by private equity takeover?

Fiore: Actually, yes. There appeared to be no effect on receiving discharge instructions or on measures of communication or hospital environmental factors like cleanliness. Study author Rishi Wadhera, MD, MPP, MPhil, told me that the lack of an impact on communication is likely “a testament to the fact that doctors and nurses continue to try to do what’s best for their patient, irrespective of who acquires their hospital and the organizational changes that occur around them as a result of the acquisition.”

Robertson: In general, private equity has taken a lot of heat recently for their involvement in healthcare, right?

Fiore: Yes. So in the past few months, private equity companies have caught the eye of Congress for their encroachment into healthcare. In September, a Senate HELP subcommittee released a report on how private equity helped run Steward Health Care into the ground. That’s the Massachusetts-based health system that went bankrupt.

Then just last week, a Senate Budget Committee report blasted two private equity companies, Apollo Global Management and Leonard Green & Partners, for a variety of problems at their hospitals, including understaffing, patient safety, and bankruptcies.

Robertson: We know that even for-profit health systems are run like businesses these days, but is there something about private equity that makes it particularly dangerous to healthcare?

Fiore: Yeah, here’s what Wadhera said when I asked him that: “I think the reason clinicians, patients, and policymakers are concerned about private equity’s growing presence in healthcare is because of the incentive structure that is in place for private equity firms to generate financial returns for their investors over short time horizons. That is at odds with doing what’s best for patient care.”

Robertson: Well thank you so much, Kristina.

Fiore: Thanks, Rachael.

Henderson: On the podcast last year, we reported on a major medical education cheating scandal. U.S. Medical Licensing Examination scores for hundreds of Nepali test takers were invalidated following an investigation, sparking a class action lawsuit. Rachael is here to update us on the situation.

Rachael, refresh our listeners’ memories of what happened.

Robertson: Sure. So last February, the USMLE announced that it had found a pattern of suspicious test results from a testing center in Nepal. They investigated, and ultimately, they invalidated the scores for 832 people — which put their careers and for many of them their visa status in limbo.

Latika Giri had all three of her scores invalidated, and shortly after all this, she launched a class action lawsuit. Eventually, that lawsuit evolved to allege discrimination based on national origin, demanding $80 million in damages. Another person joined the suit, Swechha Shrestha, who holds Nepali citizenship but lives in Nevada and had her step three score invalidated.

Henderson: Okay, so what’s new in the case?

Robertson: The latest filings are from June and July and the National Board of Medical Examiners, which co-runs the USMLE, filed a motion to dismiss, and the plaintiffs subsequently filed in opposition to that motion. Some of the related documents had some new information, notably most of the people – 618 out of 832 – only had one of their steps’ scores invalidated. Meanwhile, 202 had two scores invalidated, and just 12 people, including Giri, had all three of their steps invalidated.

Henderson: What happened to the people whose scores were invalidated?

Robertson: The USMLE gave them three options. One retake the exams for free, though if they failed this retake, they’d be barred from the test for three years. A USMLE spokesperson told me that they’ve offered all three of the steps for retakes, and they’re going to have more dates in the coming years. However, the USMLE will not be sharing any of the score data from these retakes.

The second option was to request that the USMLE reconsider the score invalidation, and that’s the option that both plaintiffs chose. And the last option is they could do nothing and have their score remain listed as ‘Score Not Available’ and then they’d also be banned from taking the exam for three years.

I spoke with Bryan Carmody, MD, who’s been following the situation pretty closely, and he told me that it makes sense that most of the people chose to retake the exam, and that passing the retake answers the question of whether or not they were knowledgeable enough to be a doctor.

He also told me that the most recent score is what’s most easily available to people who are looking. So for instance, if step one had been invalidated, but then you pass the retake, if you go on the platform, what most people in residency programs and program directors would see is “step one: pass.” Though, if they do another click, they would eventually see more. So it’s definitely something that could still impact people, but it looks as though many of them are starting to move along.

Henderson: Thanks, Rachael.

Robertson: Thank you, Jennifer.

And that is it for today. If you like what you heard, please leave us a review wherever you listen to podcasts, and please also hit subscribe. If you haven’t already, we’ll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were MedPage Today reporters Jennifer Henderson, Kristina Fiore, and Rachael Robertson. Links to their stories are in the show notes.

MedPod Today is a production of MedPage Today. For more information about the show, check out medpagetoday.com/podcasts.

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